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Events, Global Health, History, Pediatrics, Surgery, Transplants

From Costa Rica to Stanford: Pediatric liver transplant surgeon shares his story

From Costa Rica to Stanford: Pediatric liver transplant surgeon shares his story

Esquivel - croppedThese days, Carlos Esquivel, MD, PhD, is best known as one of the top pediatric liver transplant surgeons. But just a few decades ago, he worked as a generalist physician in an ill-equipped Costa Rican village located across from a river teeming with man-sized crocodiles.

Esquivel told a gripping tale of his journey from his native Costa Rica to Stanford during a recent Café Scientifque presentation. He described how he spent only a year in remote San Vito before traveling to the United States and joining the lab of innovative surgeon F.W. Blaisdell, MD, who took Esquivel under his wing and treated him like a son. On to Sweden, where Esquivel earned his post-doctorate degree, before mastering his transplantation skills with Thomas Starzl, MD, PhD, who is known as the “father of trasnplantation” and conducted the first human liver transplant in 1963.

Back then, transplant surgeons wore knee-high fishing waders to perform transplantations — they were that messy, Esquivel said. And few dared to do liver transplants in children. Fast-forward to today: Transplant surgeries are shorter, much less bloody, and much more survivable thanks to the improvements in technology and immunosuppressant drugs. Last year, the team at Lucile Packard Children’s Hospital Stanford tallied a 100 percent one-year survival rate, Esquivel told the audience.

Now, the primary problem is the shortage of organs. More than 120,000 people in the United States are waiting for a new organ. Kidneys are most in-demand, but thousands of people are also waiting for new livers. And like kidneys, livers can be taken from living donors, Esquivel said. Sometimes, an adult liver can even be split in two, saving the lives of another adult and a child.

Livers can regenerate, making it an ideal organ to donate. However, the donation surgery can cause complications and donation is a choice that potential donors — and their doctors — should consider carefully, Esquivel said.

Esquivel said surgeries are physically taxing, but also take a great deal of mental preparation. Before surgeries, he said he runs through all the scenarios, trying to prepare for every possibility.

To raise awareness about organ donation, Esquivel, an avid cyclist, completed an across-the-county bicycle race with a former transplant patient. And he has high hopes for the future. Once, transplanted livers only lasted 12 to 15 years, but today, some livers last as long as 30 years, Esquivel said.

Previously: How mentorship shaped a Stanford surgeon’s 30 years of liver transplants, Raising awareness about rare diseases and Record number of organ transplants saves five lives in a day
Photo courtesy of Lucile Packard Foundation for Children’s Health/ Toni Gauthier

Global Health, Immunology, Infectious Disease, Pediatrics, Stanford News

Researchers tackle unusual challenge in polio eradication

Researchers tackle unusual challenge in polio eradication

poliovaccinationPolio is a tricky foe. One of the biggest hurdles in the World Health Organization’s polio eradication campaign is that the virus causes no symptoms in 90 percent of people who contract it. But these silently infected individuals can still spread the virus to others by coughing, sneezing or shedding it in their feces. And those they infect may become permanently paralyzed by or die.

Polio’s evasiveness has also led to a big speed bump on the road to eliminate the disease. As I report in the current issue of Inside Stanford Medicine, scientists are trying to figure out how to stop a form of poliovirus that is derived from one type of  polio vaccine. Oral vaccines, which consist of live poliovirus that has been inactivated, can occasionally mutate in someone’s intestines to regain infectiousness. And, in rare instances, these viruses escape to the environment in feces, spreading to other people via sewage-contaminated water.

These “circulating vaccine-derived viruses” are threatening to overtake naturally occurring, “wild” poliovirus as the main source of paralysis in the communities where polio persists. The CDC’s most recent report on polio infections in Nigeria says that during the first nine months of 2014, the vaccine-derived viruses caused 22 cases of paralyzing poliomyletis, whereas wild virus caused six cases, for instance.

To tackle the problem, researchers are investigating how the injected polio vaccine, which is made with killed virus, might be substituted for the oral vaccine. The injected vaccine has some potential disadvantages for use in developing countries, so it’s not necessarily an easy substitution. In my story, Stanford’s Yvonne Maldonado, MD, who is studying the problem with a grant from the Bill & Melinda Gates Foundation, explains:

“We don’t really understand how well the killed vaccine is going to work in kids in developing countries, where there is lots of exposure to sewage, and malnutrition leaves children with weakened immune systems,” Maldonado said.

Her Gates Foundation grant examines semi-rural communities in Mexico where children now receive routine doses of the killed vaccine, followed by twice-a-year doses of the live vaccine.

“It’s an opportunity for us to study a natural experiment,” Maldonado said. Her team wants to know if the primary immune response to the killed vaccine will reduce shedding and transmission of later doses of live vaccine. They hope that starting with one or more doses of the injected vaccine will give kids the best of both worlds: from the shot, protection against circulating vaccine-derived viruses; from the oral vaccine, intestinal immunity.

Previously: TED talk discusses the movement to eradicate polio and New dollar-a-dose vaccine cuts life-threatening rotavirus complications by half
Photo of children in South Sudan receiving oral polio vaccine by United Nations Photo

Global Health, HIV/AIDS, Infectious Disease, Stanford News

Spread of drug-resistant HIV in Africa and Asia is limited, Stanford research finds

Spread of drug-resistant HIV in Africa and Asia is limited, Stanford research finds

In the last decade, millions more people in the developing world have gained access to anti-viral drugs to treat HIV, with nearly 12 million now on this life-giving treatment. But with more people on medication, there’s concern about the spread of drug-resistant strains of the virus, which can be transmitted from one individual to the next.

A new, multi-center study led by Stanford researchers offers some good news on this front: The transmission of drug-resistant strains thus far has been fairly limited in the hard-hit regions of Africa and Asia. The research involved more than 50,000 patients in 111 countries.

It is inevitable that transmitted drug resistance will increase further, so we need to continue ongoing monitoring to ensure successful, long-term treatment outcomes

“What we are showing is that the rates of transmitted drug-resistant HIV in the low- and middle-income countries most affected by HIV have increased modestly,” Stanford infectious disease expert Robert Shafer, MD, principal investigator on the study, told me. “The rate of increase in sub-Saharan Africa has been low, and an increase has not been detected in south Asia and Southeast Asia.”

Shafer is nonetheless cautious, as drug resistance remains a problem in these regions, where patients are prescribed drug regimens that are not as effective as those used in the West. And adhering to a daily regimen can be challenging for these patients, as transportation, drug supply and other issues may get in the way. Resistance can occur when there is a gap in treatment.

“It is inevitable that transmitted drug resistance will increase further, so we need to continue ongoing monitoring to ensure successful, long-term treatment outcomes for the millions of people on therapy worldwide,” Shafer said.

In the study, he and his colleagues identified four mutations that were linked to resistance to two HIV drugs, nevirapine and efavirenz. That result points to the possibility of creating a simple test that could be used to detect these mutations, he said. Clinicians then could tailor their treatment accordingly.

Another key finding was that the drug-resistant strains that did occur were not from a single line of resistant viruses, but were quite distinct. That means they developed independently, not as a result of a single transmission chain. That differs from some other microbes, such as malaria and tuberculosis, where resistant strains can move very quickly through the population.

“We are finding that the strains being detected in low-income countries are pretty much unrelated to one another,” Shafer said. “So that suggests these have not yet gained a foothold in the population and are less often being transmitted among people who have never received the drugs before.”

The study appears online today in PLoS Medicine.

Global Health, In the News, Medical Education, Pregnancy, Women's Health

Project aims to improve maternal and newborn health in sub-Saharan Africa

Project aims to improve maternal and newborn health in sub-Saharan Africa

5567854013_6bd1e2b76b_zIn sub-Saharan Africa, maternal and neonatal outcomes are some of the worst in the world. What would happen to those numbers if 1,000 new obstetrician/gynecologists were trained with state-of-the-art educational materials in the region over the next ten years? The 1000+OBGYN Project, a collaborative training effort between American and African universities, aims to do just that.

The University of Michigan’s Open.Michigan initiative, in partnership with the UM Medical School’s Department of Obstetrics and Gynecology and Department of Learning Health Sciences, just released four new collections into the 1000+OBGYN Project’s open-access database, thanks to a grant from the World Bank.

A UM press release published today describes the new contributions, which cover a diverse range of subjects, including abnormal uterine bleeding, pregnancy complications, vaginal surgeries, pelvic masses, newborn care, postpartum care and family planning. The materials are all free, publicly available, and licensed for students, teachers and practitioners to modify according to their own curricular context.

Frank Anderson, MD, MPH, associate professor in the UM Department of Obstetrics and Gynecology and director of the 1000+OBYGN Project, comments in the release:

There is an urgent need to train Obgyns [sic] in sub-Saharan Africa, but their institutions don’t always have access to the same body of educational materials as doctors in developed countries have… Many newborn and maternal deaths are preventable. We want to ensure that future Obgyns in low resource countries have access to the same high-quality learning materials available here so they are equipped to provide the best care possible for mothers and babies.

The project hopes to overcome local barriers to good education, such as availability of training materials, licensing costs, and unreliable internet access. To make the materials available offline, the initiative partnered with the Global Library of Women’s Medicine, which compresses research onto USB flash drives and distributes them globally, particularly to women’s health professionals in Africa.

Previously: Countdown to Childx: Global health expert Gary Darmstadt on improving newborn survival, Gates Foundation makes bold moves toward open access publication of grantee research, Improving maternal mortality rate in Africa through good design and Using family planning counseling to reduce number of HIV-positive children in Africa
Photo by DFID – UK Department for International Development

Ebola, Events, Genetics, Global Health, Patient Care, Pediatrics, Stanford News

Global health and precision medicine: Highlights from day two of Stanford’s Childx conference

Global health and precision medicine: Highlights from day two of Stanford's Childx conference

Childx Shah“I do think it’s possible to end preventable child death.” Those were the powerful words spoken by Rajiv Shah, MD, the former administrator of USAID, during his keynote address at the start of the second day of Stanford’s recent Childx conference. More than 6 million children die each year before age 5, mostly of easily preventible diseases, Shah told the audience.

Shah went on to describe some of the more daunting health and humanitarian crises he faced during his 5-year tenure at the helm of United States Agency for International Development, including the recent Ebola outbreak in West Africa, and the Somali famine that he helped to address with the U.S. government’s Feed the Future program. Speaking about visiting a severely overcrowded Somali refugee camp, he said, “If you looked closely, you saw signs of hope and innovation.” For instance, children were receiving the pentavalent vaccine that protects against five serious childhood diseases and that was, until quite recently, considered too expensive to distribute in this type of setting.

Shah also described how a rapid redesign of protective gear for health-care workers fighting Ebola was essential to helping get the highly contagious illness under control: The old gear was much too hot and cumbersome, as well as being difficult to remove safely, and may have been a factor in the high rates of infection among health care workers early in the Ebola outbreak. Several partners, including NASA, the Department of Defense, Kimberly-Clark and Motorola, worked together to make new protective equipment that was easier to use and better suited to intense heat.

Our capacity to innovate is essential for solving global health problems, Shah concluded. “…Saving children’s lives in resource-poor settings is not just… great and morally important,” he said. “It actually creates more stability in communities.” Families have fewer children and invest more in the education of those kids, including the girls, and the surrounding society begins to look more stable and prosperous, he said. Innovation and technology in the arena of child health are important “not just for health purposes but for shaping the kind of world that keeps us safe, secure and prosperous over many decades.”

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Global Health, Mental Health, Research, Sexual Health, Women's Health

Exploring links between domestic violence, depression and reproductive health

Exploring links between domestic violence, depression and reproductive health

abused womanIt’s no surprise that domestic violence has effects that ripple outward in a victim’s life, beyond physical traces of abuse. Research into just what those effects are can help physicians provide better counseling and treatment, and two new studies show striking correlations between domestic violence, mental illness, and contraception use.

The first study, published in Depression and Anxiety, enrolled a nationally representative sample of more than 1,000 mothers with no previous history of depression, and assessed them over 10 years. It was headed by Isabelle Ouellet-Morin, PhD, researcher at the University of Montreal. Thirty-three percent of the women reported being the victim of violence from their partner, and these women had a twofold increase in their risk of suffering from new-onset depression (after controlling for childhood maltreatment, socioeconomic deprivation, antisocial personality, and young motherhood). Compared with women who had never been victims of violence, women who were abused both in childhood and adulthood were 4-7 times more likely to suffer from depression. The results were similar for psychotic symptoms.

Louise Arseneault, PhD, co-author and professor of developmental psychology at Kings College London, is quoted in PsychCentral:

Health professionals need to be very aware of the possibility that women who experience mental health problems may also be the victims of domestic violence and vice versa. Given the prevalence of depression in these victims, we need to prevent these situations and take action. These acts of violence do more than leave physical damage; they leave psychological scars as well.

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Aging, Global Health, Medical Education, Patient Care, SMS Unplugged

After the rain: Experiencing illness as a medical student and granddaughter

After the rain: Experiencing illness as a medical student and granddaughter

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

rainy groundIn India, when the first heavy droplets of rain meet dry earth it releases a particular kind of smell: a dampness arising from sizzling soil that in Bengal we call shnoda gondho. It is raining on the second day we go to visit my grandfather in the hospital.

He has been readmitted to the hospital, after spending a week recovering at home from a hospitalization for rib fractures and bleeding into his lungs. The irony of his hospitalization is not lost on his family: that a renowned doctor, one of the first cancer surgeons in the city of Kolkata and one who spearheaded oncological care in this region, is now gowned and sitting in a hospital bed. This happens frequently, of course, for doctors are not immune to being patients, even if we would like to think so. The problem is that we are little prepared for the unstructured, unscripted nature of experiencing illness rather than treating it.

Certainly for my grandfather, a man who even recently traveled to multiple hospitals each day to supervise surgeries and see patients in clinic, being confined to bed for respiratory treatments and being unable to walk without support feels equivalent to being bound up, tied down, and chained to the hospital. This is the way illness imprisons. For his family, used to seeking his wise medical advice on various things from pesky coughs to unremitting cancers, we are unprepared to now help make decisions for him.

We never stop being medical students, and later we never stop being doctors, whether in relationships with family members, friends, acquaintances, or strangers in emergency situations

Perhaps this reflection is too personal for a forum created for sharing medical school experiences. But I suppose my realization is that medical school is not a place but rather a privilege we hold. We never stop being medical students, and later we never stop being doctors, whether in relationships with family members, friends, acquaintances while traveling, or strangers in emergency situations.

But, as I spend these three weeks with my grandfather and my family in Kolkata, I find that it is important to play both roles: that of medical student, the one who can help translate the staccato of medical jargon into fluid lines, and that of loved one, the one who listens not via an earpiece through the taut drum of a stethoscope but through bare ears and naked eyes, the one who listens for and is moved by the cries of pain, or suffering, or confusion, or desperation, of the ones they love.

In many ways the loved one is the harder role to play, for it is the role with no lines. No chest x-rays to evaluate in the morning. No medications to re-dose for a rising creatinine. No growing charts of oxygen saturation, or heart rate, or urine output. As someone who has recently grown used to doing these things on the medicine wards of Stanford Hospital, I now acculturate to a more improvisational kind of care. Placing a soothing hand on an aching back. Sitting at someone’s bedside while he nods in and out of sleep. Holding down an arm so that it doesn’t tremble like the string on a harp. In Indian hospitals, the family must often arrange to bring the medications that the doctors have prescribed and may often visit the hospital multiple times a day to bring food. We mix rice with soft, curried vegetables or boiled eggs and offer them to our loved ones, hoping to find through these labors some connection, some solace.

As family members we grasp for metaphors. In India, these metaphors of illness are often built around ideas of hot or cold, of water or wind. Perhaps that is why I find it so poignant that it rained today, the dense, gray clouds releasing their water just as the water from the pleural effusion in my dadu’s lungs was drained.

I hope that one day soon, when this rain had cleared, my grandfather will write his own words as he has planned to do. And then he can tell you his story, not I.

Amrapali Maitra is a fifth-year MD/PhD student working towards a PhD in Anthropology. She is interested in the illness experience, the cultural and social basis of health, and practices of care.   Amrapali grew up in New Zealand and Texas, and she studied history and literature as an undergraduate at Harvard. She is a 2013 Paul and Daisy Soros Fellow.  

Photo by Jason Devaun

Global Health, Pediatrics, Sexual Health, Women's Health

Rape prevention program in Kenya attracting media attention, funding

Rape prevention program in Kenya attracting media attention, funding

stop rape signI’ve written previously about No Means No Worldwide, a non-profit that has partnered with several Stanford researchers to document the success of their self-defense programs for preventing rapes of girls in Nairobi, Kenya. Over the last week, the program has garnered some wonderful news coverage of its complementary program to educate boys about their responsibility for stopping rape, including a Reuters story that describes how some schoolboys halted the sexual assault of a young girl:

Having been trained to defend girls against sexual assault, the boy called other young men to help him confront the man and rescue the child.

“It would have been fatal,” said Collins Omondi, who taught the boy as part of a program to stamp out violence against women and girls in Nairobi slums. “If this man would have assaulted this kid, he would have thrown her inside the river.”

The Reuters story also mentions some very heartening news: Thanks to funding from the British government, all of Nairobi’s 130,000 secondary school students will undergo the six-week No Means No Worldwide programs for girls and boys by the end of 2017.

Upworthy has also covered the programs’ success. From their story:

In many parts of the world, assault prevention starts and ends with what women can do to avoid putting themselves in “high-risk” situations. These are not effective.

Researchers used Kenya’s scenario to test the two methods. One group of women received the No Means No [empowerment and self-defense] training while the other took a life-skills class. Girls who received the No Means No training saw a nearly 40% decrease in rapes in the year following the program. Girls who took the life-skills offering were raped at the same rate.

Not only is teaching women how to avoid “high-risk” situations ineffective, but it shifts the blame to the victim for being raped instead of putting it on the rapist for actually committing the crime.

Committing a crime is a choice, and the No Means No program empowers young boys to choose not to commit that crime.

Previously: Empowerment training prevents rape of Kenyan girls and Self-defense training reduces rapes in Kenya
Photo by Steve McClaughin

Events, Global Health, Health Disparities, Pediatrics, Stanford News

Countdown to Childx: Global health expert Gary Darmstadt on improving newborn survival

Countdown to Childx: Global health expert Gary Darmstadt on improving newborn survival

newborn-IndiaEach year, around the world, almost 3 million babies die in the first month of life. But it doesn’t have to be that way: For many newborns, simple changes in their care could make the difference between life and death.

I spoke about this conundrum recently with global health expert Gary Darmstadt, MD, who will be among the panelists at this week’s Childx conference at Stanford. Darmstadt, who recently arrived at Stanford from the Bill & Melinda Gates Foundation, has focused much of his career on improving newborn health in developing countries. The key, he says, is engaging community members as full partners in creating the solutions for how to care for newborns. Excerpts of our conversation appear below.

Registration for the Childx conference is still open, and those who can’t attend in person can watch the conference’s live stream at the Childx website.

Preterm birth has just passed pneumonia as the No.1 cause of death, worldwide, for children under age 5, and yet many deaths from prematurity could be prevented with simple, low-tech interventions. What needs to change?

We’ve known since the late 1970s that kangaroo mother care, in which the mother keeps the infant on her chest next to her skin, is very effective. But the rate of adoption has been very poor, about 5 percent globally in 35 years.

It was originally conceived as a substitute for an incubator: By holding babies skin-to-skin you provide a constant source of warmth. What I think happened was that, by making kangaroo mother care a medical intervention rather than a natural behavior, we’ve stigmatized it. Mothers may think, “If I was a rich person, my baby would be in an incubator. Being a provider of kangaroo mother care tells me something about me and my baby: We’re second class.”

We need to communicate that kangaroo mother care is for every baby, everywhere. It’s not just something that poor people get if there aren’t enough incubators. Yes, there are situations where an incubator is helpful, but in many ways kangaroo mother care is superior. An incubator can’t provide a mother’s heartbeat or the feel of her breathing, her voice and her touch. It can’t provide breast milk. It’s not something you form a bond with that lasts for a lifetime. People have picked up the message that the medical device is superior, and they may feel like “I’m an inferior version of a medical device” rather than understanding that the medical device is, for many babies, an inferior attempt to produce what the mother or other family members can provide.

What are some key examples from your research of how social and environmental approaches can help improve infants’ health and survival?

I’m part of a team that worked closely with communities in India to understand how they perceive newborns’ needs and their issues in dealing with them. From there, we developed a simple package of preventive care. It consisted of things like holding babies skin-to-skin, breastfeeding, keeping infants warm, and basic hygiene. Once it was implemented, we saw a 50 percent reduction in neonatal mortality over a 16 month period.

We found, for example, that these communities had no real concept that hypothermia was bad for babies. They had a term for fever and understood that fever was a danger signal, but didn’t have a word that brought the connotation of harm or danger together with cold for babies. When we realized that, the community ended up coming up with a term – they called hypothermia “cold fever.” It created a whole new dialogue around hypothermia, and new openness to trying things that might be helpful to your baby, particularly skin-to-skin care.

What we really sought to do was to bring the science into language that was simple and related to their everyday experience. So the messaging became, “In the same way that when you bathe in the river, when you come out, you feel cold and wrap yourself in a sari, when a baby is born, it’s wet and feels cold, and we need to wrap up the baby for the baby’s protection.” Without understanding the social construct, the environment, we couldn’t come up with those simple messages that would become part of the social fabric.

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Global Health, Mental Health, Research, Stanford News

Study explores how cultural differences can shape the way we respond to suffering

Study explores how cultural differences can shape the way we respond to suffering

8909380232_a647e15c23_zOur emotions may be a deeply personal experience, but the way we perceive and express our feelings may not be as unique – or random – as we think. According to recent research, culture influences the way some Americans and Germans convey their mood. If this is universally true, it could mean that people of the same culture tend to express their feelings in similar ways.

As this Stanford Report story explains, researchers Jeanne Tsai, PhD, an associate professor of psychology, and Birgit Koopmann-Holm, PhD, a German citizen who earned her doctorate in Tsai’s lab, noticed that Americans of European decent and Germans seemed to differ in the way they express feelings of sympathy:

Americans tend to emphasize the positive when faced with tragedy or life-threatening situations. American culture arguably considers negativity, complaining and pessimism as somewhat “sinful,” [Tsai] added.

Unlike when Americans talk about illness, Germans primarily focus on the negative, Tsai and Koopmann-Holm wrote. For example, the “Sturm und Drang” (“Storm and Drive”) literary and musical movement in 18th-century Germany went beyond merely accepting negative emotions to actually glorifying them.

This seemingly simple observation could have important societal implications, the researchers explain: Studies show that empathy affects our willingness to help someone who is suffering. But, as noted in the article, “until now, Tsai said, no studies have specifically examined how culture shapes ‘different ways in which sympathy, compassion or other feelings of concern for another’s suffering might be expressed.'”

In their study (subscription required, pdf here), published in the Journal of Personality and Social Psychology, the researchers conducted four separate experiments on 525 undergraduate students in the U.S. and Germany to see if Americans accentuate the positive more than Germans do when expressing their condolences. The students were asked how they would feel in a variety of hypothetical situations (such as a scenario where a friend lost a loved one), what feelings they would want to avoid and how they would select and rate sympathy cards.
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